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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION i 445 N SAN JOAQUIN, PHONE (209)468-3420 9 i P 0 BOX 2009, STOCKTON, CA 95201 fi I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) i Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health 7v&,J&.A1 ices.Job Address r�Z_y/1 City)! �_ Lot Size/Acreage 11-14 Owner's Name !�&& t/t/Qr �� Address aP � Phon� B(' �,� L/ 4 r� q Contractor dressf;2 52 a/�F� SC,d�1J License Na �"�` Phone I� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service We21 ------PUMP-INSTALLATION 0._. SYSTEM REPAIR C7 _ _ OTHER 0 Monitoring Well U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD._ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C] Industrie! ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C] Domestic/Private ❑ Gravel Pack El Tracy Type of Casing_ Specifications 'I'] Public (-1 Other fl Delta Depth of Grout Seal Type of Grout 1 1 Irrigation .T.., Approx. Depth I I Eastern Surface Seal Installed by p Repair Work Done 0 Type of Pump H,P. State Work Done Well Destruction O Well Diameter Sealing Material & Depth i Depth Filler Material & Depth TYPE OF SEPTIC WORK; NEW INSTALLATION REPAIR/ADDITION ! I DESTRUCTION I I INo septic system permitted if public sewer is \ available within 200 feet.) Installation will serve: Residence _)� Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg r cd-i - ertt& _ Capacity-1-9-4-p- No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 1.etA lave- Distance.to nearest: Well Foundation�_ Property Line I.1 6 LEACHING LINE Cl No. & Length of tines + Total lengthtsize A FILTER BED C] Distance to nearest-.4 Well..iS9 Foundation J4 Property Line SEEPAGE PITS Depth ate _Size _ Number SUMPS C1 Distance to nearest: Well- Foundation.-- r - -- Property Line A14Q DISPOSAL PONDS 0 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following; "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant m Pt call for all required i spection Complete drawing on reverse side. Signed 11A Title: Date: (rs r2 FOR DEPARTMENT USE ONLY / Application Accepted by Date ren ` Pit or Grout Inspection by Date Final Inspection by 2 Date Additional Comments. Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, 6A 95201' - r- r FEE INFO AMOUNT DUE AMO/U/N[TREMITTED CASH RECEIVED BY / DATE PERMIT N0. EM 13.24 IREV.t N sl 1` ` L EN 14.20 J.r_A 1